A Psychiatrist's Toolkit: Supervising NP And PAs

A PSYCHIATRIST’S TOOKIT: Supervising NPs and PAs 2B. NC MEDICAL BOARD POSITION STATEMENT ON SUPERVISIONPhysician Supervision of Other Licensed Health Care PractitionersCreated: Jul 1, 2007, Modified: Reviewed Sept. 2012, Revised Nov. 2015The physician who provides medical supervision of other licensed healthcare practitioners is expected toprovide adequate oversight. The physician must always maintain the ultimate responsibility to assure thathigh quality care is provided to every patient. In discharging that responsibility, the physician should exercisethe appropriate amount of supervision over a licensed healthcare practitioner which will ensure themaintenance of quality medical care and patient safety in accord with existing state and federal law and therules and regulations of the North Carolina Medical Board. What constitutes an “appropriate amount ofsupervision” will depend on a variety of factors. Those factors include, but are not limited to: The number of supervisees under a physician’s supervision The geographical distance between the supervising physician and the supervisee The supervisee’s practice setting The medical specialty of the supervising physician and the supervisee The level of training of the supervisee The experience of the supervisee The frequency, quality, and type of ongoing education of the supervisee The amount of time the supervising physician and the supervisee have worked together The quality of the written collaborative practice agreement, supervisory arrangement, protocol orother written guidelines intended for the guidance of the supervisee The supervisee’s scope of practice consistent with the supervisee’s education, national certificationand/or collaborative practice agreementPhysicians should also be cognizant of maintaining appropriate boundaries with their supervisees, includingrefraining from requesting medical treatment by the physician’s supervisee. Physician assistants and nursepractitioners are specifically prohibited from prescribing controlled substances for the use of theirsupervising physicians.Practices owned solely by physician assistants or nurse practitioners may not hire or contract with physiciansto practice medicine on behalf of the physician assistant or nurse practitioner owned practice. The physicianassistant or nurse practitioner may contract with a physician to provide the legally required supervision ofthe physician assistant or nurse practitioner.NC Psychiatric Association2016

A PSYCHIATRIST’S TOOKIT: Supervising NPs and PAs 3. Hiring, Training, and SupervisingThese are only examples of how some psychiatrists approach the essential elementsof working in collaboration and are not meant to serve as official recommendations ofNCPA.One of the most important and confusing things for physicians related to supervision is how much is enough?As outlined in Section Two, North Carolina has mandatory minimum guidelines for supervision. Butremember, these are the minimal standards. In some cases, the minimum may be adequate; in others, moredirect supervision, co-signing, and frequent meetings are required. Please read carefully the NCMB ForumArticle found in Addendum A.The most important thing for a psychiatrist or any physician who works closely with NP/PAs is the physician’scomfort level with the competence of the colleague. There will be times when you need to insist on a higherlevel of supervision. Or, the NP/PA will ask for more support and supervision.As the supervising physician, you should feel empowered to set the standard for the training, oversight, andsupervision experience in your practice. This may depend on the practice setting (inpatient or outpatient),patient population (child, adult, geriatric), geographic area of the state (an urban area may have a larger,more experienced workforce), and certainly the experience and clinical training of the practitioner! Youshould not feel obligated to accept the minimum standards for any professional you are asked to supervise,even if you are employed in an agency or hospital and feel pressure to spend as little time as possible.Ultimately, your medical license is on the line with the NP/PAs who work under your supervision.Here are some real-life examples from practicing psychiatrists in various settings:Staff Psychiatrist at Major Urban Health SystemIn hiring a new NP or PA, it is important to recognize that there is a significant difference in the amount ofpsychiatric training that each of these providers has experienced. Psychiatric NPs receive more psychiatrictraining than a PA, who may have as little as a single rotation in a psychiatric setting and a few weeks oflectures. Of course, this difference in training may matter less if one is hiring an NP or PA with several yearsof psychiatric experience.In hiring an NP or PA who is straight out of training, one must realize that there is a significant investment oftime to mentor the new hire. Before hiring a recently graduated NP/PA, our system recommends speaking tothe supervisor and staff of the section/department in which the NP/PA will be working and informing themthat a recent NP/PA graduate is being considered for their department. The expectation is that the newNP/PA will require both teaching in the form of didactics, but also in everyday supervision and mentorshipduring the clinical day. Make sure that the staff is willing and capable of providing an education to the newNP/PA before hiring.Our system has embarked on a unique method of training psychiatry NPs and PAs with the establishment of aPsychiatry Advanced Clinical Practitioner (ACP) Fellowship. This is a year-long period of supplemental trainingNC Psychiatric Association2016

A PSYCHIATRIST’S TOOKIT: Supervising NPs and PAs for psychiatric NPs and for PAs who want additional intensive specialization training in psychiatry. Our ACPfellows have 16-week rotations on inpatient psychiatry, outpatient psychiatry, ED psychiatry, and consultliaison psychiatry. Additionally, they receive weekly didactics/presentations on major psychiatric topics. Casepresentations and journal club are also a part of their regular didactics.Supervision goes beyond the requirements for formal supervision. In our view at our system, supervision is adaily activity. The NP/PA must be able to access his/her supervising psychiatrist in order to staff cases or askquestions. This means that the supervising psychiatrist must be readily available, either in person on viatelephone/teleconference.Child and Adolescent Psychiatrist in a Rural CommunityAs a child and adolescent psychiatrist working as a medical director for a rural community agency that serveschildren and adolescents, I was asked to serve as a preceptor for a student NP. During the 6 monthpreceptorship, the student NP shadowed me observing all clinical activities. After a period of approximatelyone month, I observed the NP student performing different aspects of clinical work. Patients were discussedin detail with regular feedback on NP student’s performance. Once I felt the student was ready, the NPbegan seeing patients individually, with an oral presentation, and then patients were seen jointly by myselfand the student.After the completion of the preceptorship and subsequent graduation, the NP was hired to help developoutpatient psychiatric services for the agency. The Psychiatric Nurse Practitioner (PNP) and I met weekly on aformal basis and I continued to be available for informal consultation in person and by phone. I also assistedthe PNP in developing relationships with other community providers (pediatricians, therapists, etc.). Inaddition, the PNP participated in weekly clinical staff meetings that included formal lectures, clinical reviews,and oral/video case presentations.Four years later, the PNP is the primary clinician for the outpatient psychiatric services serving many childrenand adolescents in this rural area. I continue to have monthly formal meetings with the PNP and continue tobe available by phone for consultation. The formal meetings between us include discussions of specific topicsidentified by either party as areas of improvement along with presentations of complex cases. In our ruralsetting and with an NP who is a recent graduate, providing this level of supervision gives both of us peace ofmind as she practices in such a remote location.Psychiatrist in a Community HospitalIn general, introduction of a NP/PA to any psychiatric practice depends on several variable factors such aswhether he/she is freshly graduated from school, he/she has had other medical experience and istransferring to the psychiatric field, he/she has graduated from an accredited psychiatric training program, orhe/she is an experienced and accredited psychiatric PA or NP who is moving to the practice.For example, I supervise three NPs and two PAs who have varying degrees of on-the-job training in oursetting. The integration, training, and supervision are significantly different between outpatient,NC Psychiatric Association2016

A PSYCHIATRIST’S TOOKIT: Supervising NPs and PAs consult/liaison (C/L), and inpatient settings. All training should be specifically individualized between thesupervisor and supervisee.In an Inpatient setting, it is our practice for the NP/PA to shadow the psychiatrist for the first month,observing the interview, eliciting information, developing a differential diagnosis and initiating a specifictreatment plan including appropriate polypharmacy. The NP/PA will perform ancillary services and begin towrite follow-up notes. Gradually, depending on the level of achievement, the NP/PA will conduct the intakeinterview in the presence of the attending and discuss his/her thoughts on the initial diagnosis and treatment.At the end of the six months, the NP/PA should be competent to conduct a psychiatric interview andimplement the recommendation of the attending. All dictated notes and charting should be co-signed for thefirst six months. After six months, co-signing the charting is optional, depending on the bylaws of the hospital.In C/L services, the NP/PA should follow the psychiatrist for at least one month to observe the variety ofconsults. During this time, the psychiatrist will interview, formulate a diagnosis and initiate a treatment plan.The NP/PA should be given ample opportunities to observe the documentation process and charting by thepsychiatrist. The NP/PA may see the patient for the follow up, discuss the adjustment of medications andwrite a note. Between 3 to 6 months, the NP/PA may start seeing uncomplicated consults, report the findings,formulate a diagnosis and suggest a treatment plan with the psychiatrists either in person, via telepsychiatry,or by telephone. The NP/PA can document the consult findings in the chart on behalf of the attending. Aftersix months, he/she may perform uncomplicated consults independently and if needed, discuss the case withthe attending. In my experience, for the first six months, every consult should be co-signed by the attending.After six months depending on the bylaws of the hospital, co-signing can be optional.NC Psychiatric Association2016

A PSYCHIATRIST’S TOOKIT: Supervising NPs and PAs 3A. CHECKLIST FOR SUPERVISIONRegardless of the frequency of supervision as described in the prior examples, the quality of the supervisiontime is important. Many psychiatrists find it easier to structure this time. Addendum B (Suggested Checklistfor Supervision of NP/PSs) and Addendum C (Quality Improvement Meeting Form) are documents apsychiatrist could use to organize the supervision meeting and document it for the file.Addendum B is a template checklist that identifies which documents must be on site and in the file accordingto NCMB and NCBON standards, should you be audited. It also serves as a concrete vehicle for following upfrom previous sessions and noting improvements from a Quality Improvement perspective. This not onlyhelps document supervision, but it is a useful tool for discussion that should serve to improve care that isdelivered by both of the professionals. Topics or concerns that should be addressed include ethical issues,administration concerns or future topics for Quality Improvement.3B. PSYCHIATRIC CONTINUING EDUCATIONPart of supervision is also being able to make recommendations for additional education when the need oropportunity arises. You might attend a local or national meeting together. Other suggestions include:1.2.3.4.5.6.7.8.AudioDigest PsychiatryNCPA Annual MeetingLifelong Learning Modules thru AACAPFocus: The Journal of Lifelong Learning in Psychiatry (APA)Journal reviewsRisk management coursesEthics coursesPsychiatric Drug Alert; Child & Adolescent Psychiatric Alert and Psychiatric Alert NOS monthlypublicationsNC Psychiatric Association2016

A PSYCHIATRIST’S TOOKIT: Supervising NPs and PAs 3C. MONITORING QUALITY OF CAREBelow are examples of different elements of practice that can be included in a quality monitoring program.These elements can be reviewed by the psychiatrist through a record review or other means and serve as ameasure of the quality of care that the NP/PA is providing. Through this, opportunities for training andeducation can be identified. This list is not meant to be exhaustive.1. Monitoring of metabolic syndrome with antipsychotics2. Management of depression, psychotic disorders, anxiety, and bipolar disorders3. Documentation of substance use history and referral to substance abuse treatment4. Documentation on nutrition education5. Screening for substance use disorders6. Documentation of trauma history7. Justification for the use of two or more antipsychotics.8. Suicide/homicide risk assessment9. Clozapine CBC monitoring10. Appointment No ShowsNC Psychiatric Association2016

A PSYCHIATRIST’S TOOKIT: Supervising NPs and PAs 4. Requirements of Supervisory Practice AgreementsRegardless of the professional (NP or PA), a written supervisory agreement is required. This documentdescribing the practice arrangement is called “Collaborative Practice Agreement” (CPA) for NPs and“Supervisory Arrangement” for PAs. It is a written document developed and agreed upon by the supervisingphysician and NP/PA that includes the drugs, devices, medical treatment, tests and procedures that may beprescribed, ordered and performed by the NP/PA, along with a pre-determined plan for emergency services.A copy of the CPA or Supervisory Arrangement must be maintained at each practice site and reviewedannually. Neither the NC Medical Board nor the Joint Subcommittee of the Medical Board and Board ofNursing require one specific format that the PA or NP must use. However, each agreement must addresshow the NP/PA and supervising physician will operationalize NP/PA rules in that practice to comply with theadministrative code/rules.All Practice Agreements (CPA or Supervisory Arrangement) must include these common elements:1) General statements regarding what both parties (MD and NP/PA) are agreeing to do2) Availability of physician and arrangements for backup physician3) Population to be treated4) List of medications that can be prescribed including controlled substances5) Specific duties6) Emergency plans7) Quality improvement8) Mode of supervisionTwo Examples of Supervisory Practice Agreements can be found in Addendum D (for PAs) and E (for NPs).NC Psychiatric Association2016

A PSYCHIATRIST’S TOOKIT: Supervising NPs and PAs 5. Liability Implications of SupervisionLiability Implications When Supervising and Collaborating With Other Licensed Health CarePractitionersKristen Lambert, JD, MSW, LICSW, FASHRMVice President, Psychiatric and Professional Liability Risk Management GroupMoira Wertheimer, JD, RN, CPHRMAssistant Vice President, Psychiatric Risk Management GroupAWAC Services Company, a member company of Allied WorldCollaboration and supervision between medical disciplines are becoming increasingly common as there aremore patients and fewer psychiatrists to provide direct care. Nurse practitioners (NPs) and physicianassistants (PA) are becoming more widely used in psychiatry. When supervising or collaborating with otherlicensed healthcare practitioners such as NPs and PAs, there are a number of factors to consider.First, it is crucial to know what your relationship is and define your role whether you are the other provider’ssupervising physician or if another physician is in that role. There are state guidelines which you must adhereto if in a supervisory role working with NPs and PAs. As such, be aware of the requirements set forth by theNorth Carolina Medical Board (NCMB) and the regulations set forth under North Carolina law. It is alsoimportant to be aware of your role within the agency/clinic. There may be differing liability risks if in the roleas a partner/shareholder versus an independent contractor.Second, if you are not in a supervisory role, is it a collaborative relationship where there is sharedresponsibility of the patient? Whether in a supervisory or collaborative relationship, this should be identifiedat the outset of your relationship. It is important that you have an agreement in place with youragency/hospital/other licensed healthcare provider prior to beginning. Again, it is important that you areaware of your responsibilities with respect to Collaborative Practice Agreements (CPAs) and SupervisoryArrangements (SA) as set forth under the NCMB and North Carolina law.If either in the role as a supervisor or in a collaborative role, it is important to know if you will be requestedto “sign off” on another provider’s treatment notes/plan. Even if you are not in the role as the “supervisingphysician” and the other provider had a bad outcome and a lawsuit is brought, you may be included in thecase as a defendant by nature of your role in signing off on the note/plan. If being requested to “sign off,”this may have liability implications even if you did not have any involvement with the patient. In other words,know what you are signing off on.NC Psychiatric Association2016

A PSYCHIATRIST’S TOOKIT: Supervising NPs and PAs Liability Implications, continuedConclusionIn order to minimize liability exposure, it is important that all parties involved in the collaborative/supervisoryrelationship understand and abide by all aspects of North Carolina and federal law. Prior to entering such anarrangement, it is prudent for the psychiatrist to consult with a local attorney and/or risk managementprofessional.Risk Management Tips Understand your state and federal laws and regulations. Adhere to ethical guidelines (APA’s The Principles of Medical Ethics with Annotations EspeciallyApplicable to Psychiatry). Be aware of your employment contractual obligations and the policies and procedures of youragency/clinic. Define your role and have a clear de

Nurse Practitioner: A Nurse Practitioner (NP) is one of four recognized Advanced Practice Registered Nurse (APRN) roles. An APRN is an umbrella title for RNs who have completed an accredited graduate-level education program. The four APRN roles are Nurse Practitioner, Nurse Anesthetist, Nurse-Midwife or Clinical Nurse Specialist.